2009 Annual Stony Brook PA Program Winter Newsletter
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1. Please fill in all information
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1
. Year of graduation
Year of graduation
*
2
. Your Name (LN and FN)
Your Name (LN and FN)
*
3
. Home Address
Home Address
4
. Home Phone
Home Phone
*
5
. email Address
email Address
*
6
. Name and address of workplace
Name and address of workplace
7
. Work Phone
Work Phone
8
. Do you work in a state designated health professions shortage area?
Do you work in a state designated health professions shortage area?
yes
No
9
. Do you work in a federally designated health professions shortage area?
Do you work in a federally designated health professions shortage area?
yes
no
*
10
. Have you ever been an officer or committee member in a state or national Physician Assistant Organization?
Have you ever been an officer or committee member in a state or national Physician Assistant Organization?
yes
no
11
. If yes, please indicate which organization and the position that you held:
If yes, please indicate which organization and the position that you held:
*
12
. Please indicate which area(s) of medicine you are currently practicing in:
Please indicate which area(s) of medicine you are currently practicing in:
Family/General Practice
General Internal Medicine
General Pediatrics
Emergency Medicine
Orthopedics
General Surgery
Industrial/Occupational Medicine
Obstetrics/Gynecology
Geriatrics
Surgery subspecialty
Pediatrics subspecialty
Internal Medicine Subspecialty
Other (please specify)
13
. If you checked that you work in a Surgical, Pediatric or Internal Medicine subspecialty, please specify:
If you checked that you work in a Surgical, Pediatric or Internal Medicine subspecialty, please specify:
14
. If you are currently not working in healthcare, please let us know what you are doing:
If you are currently not working in healthcare, please let us know what you are doing:
15
. Is the community that you practicing:
Is the community that you practicing:
Suburban
Urban
Rural
16
. Are you currently practicing:
Are you currently practicing:
In patient only
Out patient only
Both
17
. Are you currently employed:
Are you currently employed:
Full time
part time
Other (please specify)
18
. Your current practice setting is:
Your current practice setting is:
Private practice
clinic
industrial
Hospital
Emergency room
Correctional facility
Other (please specify)
19
. Have you completed any additional training?
Have you completed any additional training?
Yes
No
If yes, please specify
*
20
. Do you currently have a graduate level degree (Masters or doctoral)?
Do you currently have a graduate level degree (Masters or doctoral)?
Yes
No
If yes, please specify title of degree, academic institution attended, and area of specialization
*
21
. If you do not hold a graduate degree, are you currently pursuing one?
If you do not hold a graduate degree, are you currently pursuing one?
yes
no
not applicable
If yes, please indicate the degree, academic institution attending, and area of specialization
22
. Please feel free to write a message in the space provided below which will be included in the final compilation of the newsletter that will be emailed to you when all of the responses are received:
Please feel free to write a message in the space provided below which will be included in the final compilation of the newsletter that will be emailed to you when all of the responses are received:
23
. We appreciate your time in filling out this survey. Please feel free to add any additional comments below.
We appreciate your time in filling out this survey. Please feel free to add any additional comments below.
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